Elsevier

Pancreatology

Volume 13, Issue 1, January–February 2013, Pages 18-28
Pancreatology

Original article
The Spanish Pancreatic Club's recommendations for the diagnosis and treatment of chronic pancreatitis: Part 2 (treatment)

https://doi.org/10.1016/j.pan.2012.11.310Get rights and content

Abstract

Chronic pancreatitis (CP) is a complex disease with a wide range of clinical manifestations. This range comprises from asymptomatic patients to patients with disabling symptoms or complications. The management of CP is frequently different between geographic areas and even medical centers. This is due to the paucity of high quality studies and clinical practice guidelines regarding its diagnosis and treatment. The aim of the Spanish Pancreatic Club was to give current evidence-based recommendations for the management of CP. Two coordinators chose a multidisciplinary panel of 24 experts on this disease. These experts were selected according to clinical and research experience in CP. A list of questions was made and two experts reviewed each question. A draft was later produced and discussed with the entire panel of experts in a face-to-face meeting. The level of evidence was based on the ratings given by the Oxford Centre for Evidence-Based Medicine. In the second part of the consensus, recommendations were given regarding the management of pain, pseudocysts, duodenal and biliary stenosis, pancreatic fistula and ascites, left portal hypertension, diabetes mellitus, exocrine pancreatic insufficiency, and nutritional support in CP.

Introduction

The objective, justification and methodology of this consensus are explained in the first part of the consensus: “Spanish Pancreatic Club recommendations for the diagnosis and treatment of chronic pancreatitis: part 1 (diagnosis)”. Briefly, two coordinators chose a multidisciplinary panel of 24 experts on this disease. These experts were selected according to clinical and research experience in Chronic Pancreatitis (CP). A list of questions was made, and two experts reviewed each question. A draft was later produced and discussed with the entire panel of experts and in a face-to-face meeting. The degree of scientific evidence was based on the ratings given by the Oxford Centre for Evidence-Based Medicine [1].

Section snippets

Which is the optimal pharmacological treatment for pain in chronic pancreatitis?

Before addressing the treatment of CP-related pain, one must rule out other possible coexisting causes, such as the presence of pseudocysts, gastric or pancreatic neoplasms, peptic ulcer disease or biliary lithiasis. It is also desirable to eliminate the cause of CP, such as alcohol or tobacco use and ductal obstruction or to provide treatment for autoimmune pancreatitis. There are few high-quality studies on the treatment of CP-related pain. Pain-relieving drugs should be administered at

What kind of endoscopic treatment is available for CP-related pain? What is the role of extracorporeal shock wave lithotripsy in the treatment of patients with CP?

Invasive pain treatment for patients with CP is indicated when medical treatment fails or when it is necessary to resort to long-term opioid administration. Endoscopic decompression treatment (EDT) is an option for treating pain in patients with dilated main pancreatic duct (increased ductal pressure) and in patients with an obstructive stones or stenosis of the ductal system [23], [24]. When recommending EDT for pain, the clinician must take into account a number of limitations: 1) Randomized

Which are the surgical treatments for pain?

Surgery in patients with CP is indicated in three scenarios: disabling pain, when pancreatic cancer is suspected and in certain CP complications.

There is no validated threshold for indicating surgery for pain control [50]. Currently there is not any available randomized controlled trial comparing surgery with conservative treatment or different timing for surgery. As stated previously we recommend considering invasive treatment in patients with pain under treatment with strong opioids that will

Which are the other interventional treatment options for chronic pancreatitis-related pain?

In general, patients with a dilated duct are candidates for endoscopic or surgical decompression, which have been addressed previously in this consensus. However, the interventional techniques that are indicated in patients without duct dilation are discussed in this section. Celiac plexus blockade has been discussed previously. These interventional techniques may also be used when decompression treatments fail. The evidence for its use is scant. Published studies lack a control group.

Bilateral

Treatment options for pancreatic pseudocyst and its complications

A pancreatic pseudocyst is a collection of fluid with high concentration of amylase, surrounded by fibrous tissue. Most studies do not distinguish between pseudocysts in acute and chronic pancreatitis and include few patients, making decision-making guidelines difficult. Most pseudocysts are small and asymptomatic [83]. Pseudocysts associated with CP are less likely to resolve spontaneously than are those associated with other disorders.

Thirty-nine per cent of pseudocysts in CP evolve to

How should CP-related biliary stenosis and duodenal stenosis be treated?

The incidence of biliary stenosis in patients with CP is variable; it may affect up to 60% of patients with a pancreatic head mass [96]. Jaundice often resolves spontaneously within the first month in 20–50% of cases, but spontaneous resolution is more unlikely the longer the jaundice persists [97], [98], [99], [100], [101]. Cholangitis occurs in 10% of cases [96].

The following have been proposed as indications of biliary drainage in CP: cholangitis episodes, a progressive increase of biliary

The diagnosis and treatment of CP-related fistulae and ascites

The communication between the pancreatic ductal system (often after the rupture of a pseudocyst) and the abdominal cavity produces pancreatic ascites, and communication with the pleural cavity produces pleural effusion. The pancreatic origin can be confirmed by elevated levels of amylase (>1000 U/L). In these cases, ERCP or magnetic resonance cholangiopancreatography (MRCP) are useful imaging techniques that sometimes help to determine the source of the leak [108], [109].

In these situations,

How to manage left portal hypertension caused by thrombosis or splenic vein stenosis

Left portal hypertension (LPH) is a syndrome of which the most serious clinical consequence is gastrointestinal bleeding caused by gastric varices. This syndrome is secondary to splenic vein obstruction [117] in most cases, being caused by thrombosis that develops during the progression of CP [118].

In most cases, the diagnosis of gastric varices can be made using conventional endoscopy. EUS can increase the diagnostic sensitivity [119]. Little is known about the natural history of patients with

Which treatment peculiarities are particular to diabetes mellitus secondary to chronic pancreatitis?

Diabetes mellitus related to CP (DM-CP) differs from DM Types 1 and 2 because it carries a greater risk of hypoglycemia resulting from the altered secretion of glucagon, which is particularly problematic in patients with inadequate compliance, alcohol consumption or autonomic neuropathy [130]; however, it is also associated with a reduced risk of diabetic ketoacidosis. Management can be difficult, especially in the advanced stages of endocrine insufficiency and after pancreatic surgery [131].

How to treat exocrine pancreatic insufficiency and how to monitor the treatment

Exocrine pancreatic insufficiency (EPI) treatment is based on the oral replacement of pancreatic enzymes to optimize the process of digesting and absorbing nutrients. Although fat, carbohydrate and protein maldigestion may occur during EPI, most authors have primarily addressed steatorrhea because it is considered an early and frequent occurrence in CP [136], [137]. Initially, oral enzyme therapy should be recommended in patients who have exhibited frank steatorrhea (>15 g/day) [138] or

Nutritional support in chronic pancreatitis: how to detect, prevent and treat the nutritional deficit

The most important underlying mechanism for malnutrition is EPI; other factors include the increase in basal energy expenditure, the coexistence of abdominal pain, diabetes and alcohol abuse [145]. Thus, it is common to find a deficit of liposoluble vitamins [146], [147], [148], [149], [150], calcium, zinc [151], [152] and, occasionally, vitamin B12 [153].

Because of this high risk of malnutrition, it is imperative to perform a thorough nutritional status assessment that includes weight,

Conclusions

The Spanish Pancreatic Club has developed the present Consensus to guide the management of CP. The paucity of well- designed randomized controlled trials, the heterogeneity of available data, and the methodological flaws of published studies are reflected in the number of grade D recommendations: 8 out of 34 (23.5%), similar to previous consensus [161]. We recommend a step-up approach to medical management of CP-related pain, based in the WHO method for pain relief, detailed in Fig. 1. The most

Conflicts of interest

Enrique de-Madaria, Enrique Domínguez-Muñoz, Julio Iglesias-García and José Lariño-Noia have been paid speakers for Abbott Laboratories. Enrique Domínguez-Muñoz is a consultant for Abbott Laboratories and Pentax. Julio Iglesias-García is a consultant for Cook Medical Company. Luis Gómez and Yolanda Sastre have been paid speakers for Mundipharma, Zambon, Ferrer Pharma and Grunenthal Pharma. José Ramón Aparicio is a consultant for Boston Scientific.

References (161)

  • B. Brand et al.

    Prospective evaluation of morphology, function, and quality of life after extracorporeal shockwave lithotripsy and endoscopic treatment of chronic calcific pancreatitis

    Am J Gastroenterol

    (2000)
  • R. Pezzilli et al.

    The quality of life in patients with chronic pancreatitis evaluated using the SF-12 questionnaire: a comparative study with the SF-36 questionnaire

    Dig Liver Dis

    (2006)
  • R. Pezzilli et al.

    Quality of life in patients with chronic pancreatitis

    Dig Liver Dis

    (2005)
  • T. Ponchon et al.

    Endoscopic stenting for pain relief in chronic pancreatitis: results of a standardized protocol

    Gastrointest Endosc

    (1995)
  • F. Gress et al.

    A prospective randomized comparison of endoscopic ultrasound- and computed tomography-guided celiac plexus block for managing chronic pancreatitis pain

    Am J Gastroenterol

    (1999)
  • J.K. Leblanc et al.

    A prospective randomized trial of 1 versus 2 injections during EUS-guided celiac plexus block for chronic pancreatitis pain

    Gastrointest Endosc

    (2009)
  • F. Gress et al.

    Endoscopic ultrasound-guided celiac plexus block for managing abdominal pain associated with chronic pancreatitis: a prospective single center experience

    Am J Gastroenterol

    (2001)
  • A.L. Warshaw et al.

    AGA technical review: treatment of pain in chronic pancreatitis

    Gastroenterology

    (1998)
  • E.L. Bradley

    Pancreatic duct pressure in chronic pancreatitis

    Am J Surg

    (1982)
  • J.R. Izbicki et al.

    Surgical treatment of chronic pancreatitis and quality of life after operation

    Surg Clin North Am

    (1999)
  • G.A. Rios et al.

    Outcome of lateral pancreaticojejunostomy in the management of chronic pancreatitis with nondilated pancreatic ducts

    J Gastrointest Surg

    (1998)
  • T. Schnelldorfer et al.

    Operative management of chronic pancreatitis: longterm results in 372 patients

    J Am Coll Surg

    (2007)
  • E.L. Bradley

    Long-term results of pancreatojejunostomy in patients with chronic pancreatitis

    Am J Surg

    (1987)
  • T. Strate et al.

    Resection vs drainage in treatment of chronic pancreatitis: long-term results of a randomized trial

    Gastroenterology

    (2008)
  • J. Koninger et al.

    Duodenum-preserving pancreatic head resection–a randomized controlled trial comparing the original Beger procedure with the Berne modification (ISRCTN No. 50638764)

    Surgery

    (2008)
  • H.C. Buscher et al.

    Limited effect of thoracoscopic splanchnicectomy in the treatment of severe chronic pancreatitis pain: a prospective long-term analysis of 75 cases

    Surgery

    (2008)
  • W.H. Nealon et al.

    A unifying concept: pancreatic ductal anatomy both predicts and determines the major complications resulting from pancreatitis

    J Am Coll Surg

    (2009)
  • L.C. Hookey et al.

    Endoscopic drainage of pancreatic-fluid collections in 116 patients: a comparison of etiologies, drainage techniques, and outcomes

    Gastrointest Endosc

    (2006)
  • K.E. Behrns et al.

    Surgical therapy of pancreatic pseudocysts

    J Gastrointest Surg

    (2008)
  • S. Varadarajulu et al.

    EUS versus surgical cyst-gastrostomy for management of pancreatic pseudocysts

    Gastrointest Endosc

    (2008)
  • E.J. Balthazar et al.

    Hemorrhagic complications of pancreatitis: radiologic evaluation with emphasis on CT imaging

    Pancreatology

    (2001)
  • Oxford center for evidence-based medicine

    (2012)
  • World health organization

    (1986)
  • L.F. Prescott

    Paracetamol, alcohol and the liver

    Br J Clin Pharmacol

    (2000)
  • R.C. Dart et al.

    Treatment of pain or fever with paracetamol (acetaminophen) in the alcoholic patient: a systematic review

    Am J Ther

    (2000)
  • E.K. Kuffner et al.

    Effect of maximal daily doses of acetaminophen on the liver of alcoholic patients: a randomized, double-blind, placebo-controlled trial

    Arch Intern Med

    (2001)
  • S. Maj et al.

    A prospective study of the incidence of agranulocytosis and aplastic anemia associated with the oral use of metamizole sodium in Poland

    Med Sci Monit

    (2004)
  • L. Ibanez et al.

    Agranulocytosis associated with dipyrone (metamizol)

    Eur J Clin Pharmacol

    (2005)
  • G.W. Basak et al.

    Update on the incidence of metamizole sodium-induced blood dyscrasias in Poland

    J Int Med Res

    (2010)
  • C.H. Wilder-Smith et al.

    Effects of morphine and tramadol on somatic and visceral sensory function and gastrointestinal motility after abdominal surgery

    Anesthesiology

    (1999)
  • T. Niemann et al.

    Opioid treatment of painful chronic pancreatitis

    Int J Pancreatol

    (2000)
  • H. Halgreen et al.

    Symptomatic effect of pancreatic enzyme therapy in patients with chronic pancreatitis

    Scand J Gastroenterol

    (1986)
  • J. Mossner et al.

    Treatment of pain with pancreatic extracts in chronic pancreatitis: results of a prospective placebo-controlled multicenter trial

    Digestion

    (1992)
  • A. Malesci et al.

    No effect of long-term treatment with pancreatic extract on recurrent abdominal pain in patients with chronic pancreatitis

    Scand J Gastroenterol

    (1995)
  • G. Isaksson et al.

    Pain reduction by an oral pancreatic enzyme preparation in chronic pancreatitis

    Dig Dis Sci

    (1983)
  • L. Czako et al.

    Quality of life assessment after pancreatic enzyme replacement therapy in chronic pancreatitis

    Can J Gastroenterol

    (2003)
  • N. Shafiq et al.

    Pancreatic enzymes for chronic pancreatitis

    Cochrane Database Syst Rev

    (2009)
  • P. Bhardwaj et al.

    A randomized controlled trial of antioxidant supplementation for pain relief in patients with chronic pancreatitis

    Gastroenterology

    (2009)
  • P. Dite et al.

    A prospective, randomized trial comparing endoscopic and surgical therapy for chronic pancreatitis

    Endoscopy

    (2003)
  • D.L. Cahen et al.

    Endoscopic versus surgical drainage of the pancreatic duct in chronic pancreatitis

    N Engl J Med

    (2007)
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